Provider Demographics
NPI:1649805961
Name:DEFOOR, MIKALYN T (MD)
Entity type:Individual
Prefix:
First Name:MIKALYN
Middle Name:T
Last Name:DEFOOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:WILFORD HALL AMBULATORY SURGICAL CENTER
Mailing Address - Street 2:1100 WILFORD HALL LOOP, BLDG. 4554, 59 MDW/GME
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9908
Mailing Address - Country:US
Mailing Address - Phone:210-916-1284
Mailing Address - Fax:210-916-7323
Practice Address - Street 1:SAN ANTONIO MILITARY CENTER, MCHE-ZSO, ORTHOPAEDIC RES
Practice Address - Street 2:3551 ROGER BROOKE DR.
Practice Address - City:JBSA-FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-1284
Practice Address - Fax:210-916-7323
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101274515208D00000X
CODR.0075016207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty